Ahmed v. TD General Insurance Company, 2026 CanLII 48395

Citation: Ahmed v. TD General Insurance Company, 2026 ONLAT 24-013921/AABS

Licence Appeal Tribunal File Number: 24-013921/AABS

In the matter of an application pursuant to subsection 280(2) of the Insurance Act, RSO 1990, c I.8, in relation to statutory accident benefits.

Between:

Baseer Ahmed

Applicant

and

TD General Insurance Company

Respondent

DECISION

ADJUDICATOR: John Mazzilli

APPEARANCES:

For the Applicant: Maka Metreveli, Paralegal

For the Respondent: Antonella Santi, Counsel

HEARD: By way of written submission

OVERVIEW

1Baseer Ahmed, (“the applicant”), was involved in an automobile accident on September 29, 2021, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”). The applicant was denied benefits by TD General Insurance Company (“the respondent”) and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

PRELIMINARY ISSUES

2Is the applicant barred from proceeding to a hearing for the following benefits: Substantive Issues ii., iii., iv., v., vi. and vii. because the applicant failed to dispute the respondent’s denials within the 2-year limitation period?

SUBSTANTIVE ISSUES

3The substantive issues in dispute are:

i. Are the applicant’s injuries predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the $3,500.00 Minor Injury Guideline limit? The parties agree the MIG limits have not been exhausted. The amount paid to date is $1,986.08.

ii. Is the applicant entitled to $2,410.66 for chiropractic services, proposed by 101 Physio in a treatment plan/OCF-18 (“plan”) submitted March 25, 2022, and denied March 31, 2022?

iii. Is the applicant entitled to $2,460.00 for a psychological assessment, proposed by 101 Assessments in a plan submitted May 9, 2022, and denied May 20, 2024?

iv. Is the applicant entitled to $2,560.00 for psychological services, proposed by 101 Assessment in a plan submitted June 10, 2022, and denied June 23, 2022?

v. Is the applicant entitled to $2,460.00 for an orthopaedic assessment, proposed by 101 Assessments in a plan submitted July 11, 2022, and denied July 22, 2022?

vi. Is the applicant entitled to $2,460.00 for a neurological assessment, proposed by 101 Assessments in a plan submitted July 11, 2022, and denied July 22, 2022?

vii. Is the applicant entitled to $2,460.00 for a cognitive assessment, proposed by 101 Assessments in a plan submitted July 18, 2022, and denied July 22, 2022?

viii. Is the applicant entitled to $2,460.00 for a driving evaluation, proposed by 101 Assessments in a plan submitted November 23, 2022, and denied November 30, 2022?

ix. Is the applicant entitled to $2,460.00 for a neuropsychological assessment, proposed by 101 Assessments in a plan submitted November 23, 2022, and denied November 30, 2022?

x. Is the applicant entitled to $2,460.00 for a chronic pain assessment, proposed by 101 Assessments in a plan submitted March 20, 2023, and denied April 3, 2023?

xi. Is the applicant entitled to $2,460.00 for a psychiatry assessment, proposed by 101 Assessments in a plan submitted March 7, 2023, and denied March 8, 2023?

xii. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

4The applicant is barred from proceeding to a hearing for issues ii., iii., vi., v, vi, and vii, above pursuant to section 56 of the Schedule, and I decline to exercise my discretion to extend the limitation period under section 7 of the Licence Appeal Tribunal Act (“LAT Act”).

5The applicant remains in the MIG; therefore, it is not necessary to determine whether the assessments and treatment plans are reasonable and necessary.

6The respondent’s denial letter for issue xi complies with s.38(8) of the Schedule.

7As no benefits are owing, interest is not owing.

8The application is dismissed.

ANALYSIS

Preliminary Issue - Section 7 & 56

9I find that the applicant is barred from proceeding to a hearing for claiming entitlement to issue ii., iii, iv., v.vi., and vii above because he failed to dispute the respondent’s denial notices within the 2-year limitation period. In addition, I choose not to exercise my discretion under section 7 of the Licence Appeal tribunal ACT, 1999 (“LAT Act “) to extend the applicant’s deadline to file an application.

10Pursuant to section 56 of the Schedule, the applicant has two years from the date of the denial to apply to the Tribunal to dispute the respondent’s decision. The limitation clock begins once the applicant receives proper notice of the denial. The notice must clearly and unequivocally deny the benefit, provide the medical and any other reasons for the decision, and must include information on the applicant’s right to dispute the decision.

11It is well established that, to determine whether a denial is proper, it must be in accordance with the principles outlined in Smith v Cooperators General Insurance Company, 2002 SCC 30 (“Smith”). The Court of Appeal in Sietzema v. Economical Mutual Insurance Company, 2014 ONCA 111 confirmed that the limitation period is triggered once proper notice of denial is provided regardless of the correctness of the insurer’s reasons for denial.

12If the respondent’s denial satisfies these requirements and the applicant fails to dispute the respondent’s denial within two years, then the onus is on the applicant to establish reasonable grounds for an extension under Section 7 of the LAT Act. Section 7 allows the Tribunal to extend a limitation period for filing an appeal. In considering whether to exercise its discretion to extend the limitation period, the Tribunal must consider the following four factors set out in Manuel v. Registrar, 2012 ONSC 1492 (”Manuel”),to determine if the justice of the case requires the extension. The factors that the Tribunal considers on a request for an extension of time are the existence of a bona fide intention to appeal within the appeal period; the length of the delay; prejudice to the other party; and the merits of the appeal.

13The respondent argues that all its denials for the disputed treatment and assessment plans were provided in writing, with clear, unequivocal, and straightforward reasons, and included information about the relevant time limits as set out in Smith. It further argues that the applicant has failed to establish reasonable grounds for an extension under Section 7 of the LAT Act.

14The applicant argues that the respondent’s denials are not in accordance with s.38(8) of the Schedule because proper medical and other reasons were not provided by the respondent’s denial letters., therefore issues ii, ii, iv, v, vi and vii are not subject to the limitation period.

The respondent’s denials of the benefits sought by the applicant contained clear and unequivocal reasons and advised the applicant of his right to dispute its denials.

15I find on a balance of probabilities that the applicant is non compliant with s.56 of the Schedule because he failed to dispute the respondent’s denials within two years for issues ii, iii, iv, v,vi and vii above and because I find on a balance of probabilities that the respondent’s denials for issues ii, iii, iv, v, vi and vii above are clear and unequivocal and advised the applicant of his right to dispute. For these reasons I find that the applicant is barred from proceeding to a hearing for issues ii., iii., vi., v, vi, and vii, above pursuant to section 56 of the Schedule, and I decline to exercise my discretion to extend the limitation period under section 7 of the LAT Act.

16I disagree with the applicant’s arguments that the respondent’s denial letters are not in accordance with s.38(8). Smith informs that straightforward and clear language be used for an unsophisticated person to understand and a description of the most important points of the dispute resolution process, and the relevant time limited requirements that govern the adjusting process.

17After review of the respondent’s denials, which I briefly outline below, I find on a balance of probabilities that the respondent’s denials for issues ii., iii., iv., v., vi., and vii. above were provided in writing, containing clear and unequivocal information for its denial and included relevant time limits in accordance with the principles set out in Smith. The current application was brought forth on November 12, 2024, the limitation period expired for issue ii on March 31, 2024, issue iii limitation period expired on May 19, 2024, issue iv. limitation period expired on June 23, 2024, issue v. limitation period expired July 22, 2024, issue vi. limitation period expired on July 22, 2024, issue vii., limitation expired July 22, 2024.

Issue ii-Chiropractic services

18The plan is in the amount of $2,410.66 for chiropractic services was submitted on March 25, 2022, and denied in letter dated March 31, 2022. The letter advised the applicant that the respondent’s denial was because it had no supporting medical documentation provided that indicate injuries from the accident, nor the existence of a pre-existing medical condition that would prevent the applicant from achieving maximum medical recovery within the confines of the MIG. The denial letter further informs the applicant of his ability to dispute the denial within the two-year time limit or that he will lose the right to dispute in the alternative.

Issue iii.-Psychological assessment

19The psychological assessment is in the amount of $2,460.00 and was submitted May 9, 2022, and denied by the respondent by way of letter dated May 19, 2022. The respondent denied the assessment on the basis that it had no supporting medical documentation indicating injuries from the accident or the existence of a pre-existing medical condition that warrants removal form the MIG and further advised the application that an insurers examination would be required for reconsideration. The denial letter further informs the applicant of his ability to dispute the denial within the two-year time limit or that he will lose the right to dispute in the alternative.

Issue iv.-Psychological services

20The psychological services plan was submitted on June 10, 2022, and denied by the respondent on June 23, 2022, based on the MIG limits and advised the applicant that he failed to complete the psychological insurer’s examination due to his inappropriate behavior, and advised the applicant that he would be required to attend another examination for consideration of the plan. The denial letter further informs the applicant of his ability to dispute the denial within the two-year time limit or that he will lose the right to dispute in the alternative.

Issue v, vii, and vii.-Orthopaedic, neurological and cognitive assessments

21The orthopedic assessment and the neurological assessment were submitted on July 11, 2022, and the cognitive assessment was submitted on July 18, 2022. The respondent denied all three of the assessments by way of a letter dated July 22, 2022. The letter advised the applicant that the assessments were denied because the applicant did not provide any supporting medical documentation that indicate injuries from the accident or the existence of a pre-existing medical condition that would preclude his recovery within the confines of the MIG. The denial letter further informs the applicant of his ability to dispute the denial within the two-year time limit or that he will lose the right to dispute in the alternative.

22Based on the above notices, I find that the respondent provided straightforward and clear language for an unsophisticated person to understand its denials and a description of the most important points of the dispute resolution process. The respondent’s denial notices clearly and unequivocally denied the benefit, provided medical and any other reasons for the decision, and include information on the applicant’s right to dispute the decision within the two-year time limit.

23For these reasons above, I find on a balance of probabilities that the applicant is barred from proceeding to a hearing for issues ii., iii., vi., v, vi, and vii, above pursuant to section 56 of the Schedule, and I decline to exercise my discretion to extend the limitation period under section 7 of the LAT Act because the applicant did not provide any submissions to support an extension under section 7.

Substantive Issue Analysis

Minor Injury Guideline

24I find on a balance of probabilities that the applicant has failed to demonstrate that his accident-related injuries warrant treatment beyond the limits of the MIG.

25Section 18(1) of the Schedule provides that medical and rehabilitation benefits are limited to $3,500.00 if the insured sustains impairments that are predominantly a minor injury. Section 3(1) defines a “minor injury” as “one or more of a sprain, strain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and includes any clinically associated sequelae to such an injury.”

26An insured may be removed from the MIG if they can establish that their accident-related injuries fall outside of the MIG or, under s.18(2), that they have a documented pre-existing injury or condition combined with compelling medical evidence stating that the condition precludes recovery if they are kept within the confines of the MIG. The Tribunal has also determined that chronic pain with a functional impairment or a psychological condition may warrant removal from the MIG. In all cases, the burden of proof lies with the applicant.

27In this case the applicant argues that he should be removed from the MIG due to the physical and psychological injuries sustained in the accident.

Physical Injuries

28I find on a balance of probabilities that the applicant has failed to on his onus to prove that his accident-related physical injuries warrant removal from the MIG.

29The applicant submits that at the time of the accident he was living in a half-way house and was on parole for previous offences and due to the accident he was not able to meet the terms of his parole which required him to return to the half-way house by a pre-arranged time and as a result he was arrested and incarcerated for four months.

30He submits that due to his incarceration he was unable to seek medical attention following the accident, until such time as a medical professional appointment was arranged. He submits that the clinical notes and records (“CNRs”) from Toronto South Detention Centre note complaints of head injury 6 to 7 days ago (prior to his incarceration), back pain, anxiety and depression as well as cough. He submits that he hit his head on the car steering wheel which caused him to suffer a concussion with symptomology presenting as headaches with episodes of blurry vision and dizziness. The applicant relies on the CNRs from various physicians at Correctional Service Canada.

31The respondent argues that following the accident the applicant exited his vehicle independently and left the scene. It argues that the applicant did not report loss of consciousness and did not sustain any lacerations or bruises. It argues that the applicant did not seek medical attention until October 6, 2021, while incarcerated. It argues that while the applicant allegedly suffered from concussion symptoms, these symptoms had eased by December 30, 2021. It argues that the CNRs from the applicant’s family physician do not mention accident-related injuries and that it has not received any updated medical records from a general practitioner, a physiotherapy clinic or a treating psychological profession with accident-related injuries.

32I find on a balance of probabilities that the applicant has failed to prove that he suffers from an accident-related concussions that warrants treatment beyond the limits of the MIG. The CNRs from Correctional Services Canada show that the applicant self reported to the correctional physician that he hit his head on the steering wheel of the car and he ran away from the scene. A progress note dated October 12, 2021, shows that the applicant had no injuries at this time, however he complained of concussion symptoms. The applicant’s self reported symptomology without a formal diagnosis of a concussion does not support his onus to prove entitlement beyond the limits of the MIG.

33While a concussion is a condition that warrant’s treatment beyond the limits of the MIG, I was not pointed to a formal diagnosis of a concussion, but rather a CNR from Beaver Creek institution dated November 25, 2021 shows that the applicant possibly suffered from a concussion as he complained of headache and dizziness though gradually diminishing at this time, and by December 31, 2021, approximately 3 months post accident the CNRs of Dr. Cross shows that the applicant’s headaches and dizziness have eased.

34The applicant sought medical attention on 5 separate occasions from January of 2022 to April 20, 2022, however none of these CNRs reference any concussions symptomology or accident-related injuries, which to me demonstrates that the applicant’s self reported concussive symptomology does not warrant treatment beyond the limits of the MIG because there is no medical diagnosis of a concussion from a physician.

35I find on a balance of probabilities that the applicant has failed to demonstrate that he suffered from an accident-related concussion that warrants treatment beyond the limits of the MIG.

Psychological Injuries

36I find on a balance of probabilities that the applicant has failed to establish that he suffers from a psychological condition that warrants removal from the MIG.

37The applicant submits that as a result of the accident he suffers from adjustment disorder (with mixed anxiety and depressed mood), specific isolated phobia (driver and passenger) and somatic symptom disorder with predominant pain. The applicant submits that the psychological report of Dr. Papazoglou shows that the applicant clearly is suffering from psychological injuries and therefore he should be removed from the MIG. He submits that the respondent’s s.44 assessor’s objective testing clearly shows that he suffers from a psychological injury. The applicant relies on the report of Dr. Papazoglou, psychologist dated June 2, 2022.

38The respondent argues the applicant does not suffer from a psychological injury that warrants removal from the MIG. It argues that the CNRs from the applicant’s family physician do not reference any psychological complaints or injury from the accident. It argues that it had to reschedule a s.44 psychological assessment because the applicant was rude and inappropriate towards the assessor, Dr. Syed. It argues that the subjective and objective testing completed by Dr. Seon (assessor #2) do not show the applicant having a psychological injury that warrants funding beyond the limits of the MIG. The respondent relies on the psychological reports of Dr. Seon, psychologist dated August 18, 2022, August 31, 2023, and May 9, 2024, and the CNRs of the applicant’s family physician, Dr. Sobia, which shows that the applicant does not suffer from a diagnosable psychological condition.

39I agree with the respondent, namely because Dr. Papazoglous’ opinion is contrary and inconsistent with the evidence. The CRNs of Dr. Sobia do not mention any accident-related psychological injuries. While the August and September 2023, CRNs of Dr. Sobia do mention the applicant was experiencing low mood, feeling depressed and lashing out, Dr. Sobia attributes these symptoms to the applicant’s fear of going back to prison and the stressors associated with employment and his financial stability and not the subject accident.

40In addition, I placed more weight to the report of Dr. Seon because her assessment of the applicant consisted of an approximately three hours in person assessment whereas Dr. Papazoglou’s assessment of the applicant was conducted by telephone and was approximately one and half hours in duration. I find Dr. Seon assessment to more complete and persuasive because she was able to provide clinical observations based on her in person assessment whereas Dr. Papazoglou’s telephone assessment is less complete because clinical observations of the applicant are lacking. For example, Dr. Seon in her report noted that the applicant presented as calm, pleasant, and easily engaged. He maintained appropriate eye contact throughout the duration of the assessment. There were no abnormalities regarding his appearance or behaviour. There were no abnormalities regarding his movements or mannerisms. In my view these clinical observations of the applicant are not possible to attain during a telephone assessment.

41In addition, at the request of the applicant Dr. Seon provided the applicant the assistance of a reader/writer because the applicant noted that he cannot focus and read testing for too long, whereas Dr. Papazoglou’s report is silent on how or when the psychometric testing was performed.

42Finally, Dr. Seon’s testing included objective psychometric testing such as the Test of Memory Malingering (“TOMM”) whereas Dr. Papazoglou’s assessment did not provide the objective TOMM test which confirms the validity and accuracy of the applicant’s testing results. The applicant’s scores in the TOMM do not suggest that he suffers from a psychological condition that warrants removal from the MIG. His testing result is as follows:

“Mr. Ahmed completed the [TOMM]. His scores on the TOMM, test sensitive to motivation and effort, fell considerably below expectation, and raised serious concerns about whether he put forth his best effort on all other tests. These findings make it difficult, if not impossible, to validly interpret his other scores. It is questioned if maximum effort was put forth, and, unfortunately, symptom magnification (intentional or not) cannot be ruled out at this time.”

43For the reasons above I accept Dr. Seon’s opinion that “There were no objective or valid findings to support a psychological diagnosis in direct relation to the injuries sustained in the motor vehicle accident of September 29, 2021. Mr. Ahmed denied experiencing any significant symptoms of anxiety, panic, or avoidance behaviour travelling in or operating a vehicle that negatively interfered with his overall level of functioning.”

44For the reasons above I find on a balance of probabilities that the applicant has failed to demonstrate that he suffers from a psychological condition that would warrant treatment beyond the limits of the MIG.

Are the respondent’s denial letters in accordance with s.38(8) of the Schedule?

45Section 38(8) reads that within 10 business days after it receives the treatment and assessment plan, the insurer shall give the insured person a notice that identifies the goods, services, assessments and examinations described in the treatment and assessment plan that the insurer agrees to pay for, any the insurer does not agree to pay for and the medical reasons and all of the other reasons why the insurer considers any goods, services, assessments and examinations, or the proposed costs of them, not to be reasonable and necessary.

46Section 38(11) is operative if the insurer fails to give a notice in accordance with subsection 38(8) in connection with a treatment and assessment plans. Section 38(11) states that the insurer is prohibited from taking the position that the insured person has an impairment to which the Minor Injury Guideline applies. Further, the insurer shall pay for all goods, services, assessments, and examinations described in the treatment and assessment plan that relate to the period starting on the 11th business day after the day the insurer received the application and ending on the day the insurer gives a notice described in subsection (8).

47The applicant provided s.38(8) arguments for one treatment plan outside of the barred issues, namely a psychiatric assessment which I will address.

Issue xi.-$2,460.00 for a psychiatry assessment, proposed by 101 Assessments in a plan submitted March 7, 2023, and denied March 8, 2023

48The applicant submits that while the denial was provided based on the s.44 psychological assessment by Dr. Sion dated August 18, 2022, the report pre-dates the OCF-18 dated January 31, 2023, which was submitted to the respondent on March 5, 2023. He argues that the denial does not quote any medical opinion offered by Dr. Seon, and the denial letter dated May 20, 2024, does not include Dr. Seon’s report.

49The respondent argues that the plan was denied pending completion of an insurer’s examination with respect to the MIG, which the applicant had failed to attend. It argues that on May 20, 2024, it advised the applicant that the plan remained denied based on the MIG determinations of Dr. Seon and Dr. Loritz based on the s.44 physical and psychological assessments.

50The plan was originally denied on March 8, 2023, by way of letter by the respondent. Its denial identified the applicant’s MIG status and provided the following reason for its denial of the OCF-18 prepared by Dr. Yaroshevsky for a psychiatric assessment in the amount of $2,460.00.

“As per our September 12, 2022, letter, you were non-compliant in attending and participating in Insurer’s examinations that were arranged with regards to your Minor Injury Guideline Determination following the denial of three Treatment and Assessment Plans (OCF-18) also submitted by 101 Assessment Centre. As a result of your noncompliance, you were advised that should you wish to attend the examinations we would be pleased to have them scheduled. However, prior to rescheduling the examinations we would require written confirmation from you stating that you are willing to attend and participating in the examinations. To date we have received no such correspondence form you.”

51In my view the respondent provided clear and concise reasons for its denial, because it advised the applicant for the reason the plan was denied, namely his noncompliance in attending and participating in the assessment and advised him of his need to attend the assessment and information on how to reschedule the assessment, which in my view satisfy the requirements under s.38(8).

Respondent’s letter of September 5, 2023

52I find on a balance of probabilities that the respondent’s denial letter of September 5, 2023, is in accordance with s.38(8).

53In its letter to the applicant the respondent provided the report of Dr. Seon with medical and or other reasons for its denial, it attached Dr. Seon’s report and provided supportive information as to why the applicant was not being removed from the confines of the MIG, the letter informs that the respondent maintains its position from a previous letter. Part of the letter reads “The current psychological assessment, including a review of additional documentation, subjective reports and objective psychometric findings, has not altered the opinions outlined in the initial report, dated August 18, 2022”.

54I find that the respondent’s letter dated September 25, 2023, satisfies the requirements under s.38(8) because the respondent provided medical and other reasons that are the same considerations from its previous denial and maintained its reasons for the current denial.

Denial letter dated May 20, 2024

55I find on a balance of probabilities that the respondent’s denial letter for issue xi dated May 20, 2024, does comply with s.38(8) and the assessment was previously properly denied as noted above in accordance with s.38(8).

56This letter serves the applicant as a denial letter for various treatment and assessments, and in the absence of new medical evidence from the applicant that would support the assessment the letter does not require to provide additional reasons for the same previously denied assessment of May 8, 2023, and September 25, 2023, and I find that the information provided for it’s denial is sufficient to meet the requirements under s.38(8).

57This letter informs that it is a “follow up from previous letter dated August 24, 2022, in which based on the report of the examination required by insurer, dated August 18, 2022, and completed by Dr. Terra Seon, we determined that the injuries you sustained in the motor vehicle accident fall under the Minor Injury Guideline. As noted above the plan had already previously been properly denied by the respondent in accordance with s.38(8) and continues to be denied on May 20, 2024. The letter continues to provide medical reasons for the applicant’s physical injuries, and its opinion on pre-existing conditions that do not satisfy his removal from the MIG.

58Accordingly, I find on a balance of probabilities that the respondent’s denial letter for issue xi complies with s.38(8).

The disputed treatment and assessments

59The applicant remains in the MIG; therefore, it is not necessary to determine whether the assessments and treatment plans are reasonable and necessary.

Interest

60Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are owing, interest is not owing.

ORDER

61It is ordered that:

i. The applicant is barred from proceeding to a hearing for issues ii., iii., vi., v, vi, and vii, above pursuant to section 56 of the Schedule.

ii. The applicant remains in the MIG; therefore, it is not necessary to provide an analysis of the disputed treatment and assessment plans.

iii. The respondent’s denial letter for issue xi complies with s.38(8) of the Schedule.

iv. As no benefits are owing interest is not owing.

v. The application is dismissed.